Feb 23, 2024 Assessing the Genitalia and Rectum Discussion: NURS 6512 Week 10
Assessing the Genitalia and Rectum Discussion: NURS 6512 Week 10
Assessing the Genitalia and Rectum Discussion: NURS 6512 Week 10
Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities, respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone.
This paper explores the potential history, physical exam, and differential diagnosis based on a case scenario of T.S., a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for three months.
Subjective
A triad of urgency, frequency, and dysuria characterizes a pathology most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections.
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Similarly, it is important to inquire about abnormal vaginal discharge and burning sensation during urination since she is sexually active, and a sexually transmitted infection might cause her symptoms.
Likewise, changes in the smell and color of the urine must be elicited, as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in their partner or the use of protection during intercourse (Garcia & Wray, 2022).
Similarly, her last menstrual period must be known to determine if she is pregnant, which will impact the management (Bono et al., 2022). Additionally, a history of medication use, alcohol, smoking, and use of illicit drugs must be elicited.
A history of contact with an individual with a chronic cough or T.B. before the previous symptoms must be elicited as urogenital T.B. may present similarly. Finally, it is crucial to inquire about any history of trauma or recent urethral catheterization, as these are common risk factors for urinary tract infections.
Objective
The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutritional status of the patient must be noted. A complete abdominal exam must also be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022).
Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must exclude associated rectal abnormalities.
Assessment
In addition to urinalysis, STI, and pap smear testing, a complete blood count and urine culture must be conducted as the patient presents with signs of infection. Similarly, a pregnancy test must be conducted as this may complicate urinary tract infections. Additionally, she has no appetite, so random blood sugar must be done to exclude hypoglycemia.
Similarly, urea, creatinine, and electrolyte must be conducted to check the renal function as the patient has flank pain. Finally, Inflammatory markers such as ESR, CRP, and blood cultures must be done as the patient has flank pain that may indicate pyelonephritis (Bono et al., 2022). Imaging tests are not necessary for the diagnosis of lower UTI.
However, the patient has flank pain, and therefore, a C.T. scan of the abdomen and pelvis with or without IV contrast as well as an ultrasound of the kidneys and bladder, must be done to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022)
The possible diagnoses include a urinary tract infection and a sexually-transmitted infection. Urinary tract infections refer to the infection of the bladder, urethra, ureters, or kidneys (Bono et al., 2022). UTIs are more common in women due to a short urethra and proximity of the anal and genital regions (Bono et al., 2022).
A triad of frequency, dysuria, and urgency collectively defines the irritative lower urinary tract symptoms (Bono et al., 2022). Similarly, suprapubic tenderness is a key feature of lower urinary tract infections. However, the patient is also feverish and has flank pain which also denotes the potential for involvement of the upper urinary tract (Bono et al., 2022). T.S. is also sexually active, a risk factor for urinary tract infection.
A sexually transmitted infection is another possible diagnosis. T.S. is sexually active and has had her new partner for the last three months, a key risk factor for this condition (Garcia & Wray, 2022). Most STIs present with suprapubic pain. Most STIs are asymptomatic and, if symptomatic, manifest with urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S. was negative for the features above.
Other differential diagnoses include pyelonephritis, interstitial cystitis, and urethritis due to an STI. Pyelonephritis is of the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a complication of ascending bacterial infection of the bladder and manifests principally with frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022).
Interstitial cystitis is a chronic noninfectious idiopathic cystitis associated with recurrent suprapubic pain (Daniels et al., 2018). It presents with urgency, frequency, suprapubic discomfort, and pain relieved by voiding. T.S. has some of these features, although the gradual onset of symptomatology and more than six weeks is required to diagnose this condition (Daniels et al., 2018). Finally, urethritis secondary to an STI may present in females with only frequency, urgency, and dysuria with minimal or no vaginal discharge (Young et al., 2022).
Conclusion
Assessment of the genitalia and rectum is sensitive and may help identify rectum and genitourinary tract abnormalities. Most abnormalities of the genitourinary system, particularly UTIs and STIs, can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.
References
Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/30137822/
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/
Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy, 32(1), 49–58. https://doi.org/10.1080/15360288.2018.1476433
Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/
Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis. https://pubmed.ncbi.nlm.nih.gov/30725967/
Patients are frequently uncomfortable discussing with healthcare professionals issues that involve the genitalia and rectum; however, gathering a good history and properly conducting a physical exam is vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to assess patients with problems in these areas accurately.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion.
Also, your Discussion post should be in the SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Assessing the Genitalia and Rectum Discussion Case 1: Rectal Bleeding
A 62-year-old male construction worker reports to your clinic after experiencing rectal bleeding for over one month. He has noticed small amounts of blood after every bowel movement. He had a colonoscopy two years ago with normal results.
The patient has no fever, chills, dysuria, abnormal urinary frequency, or abdominal pain. The patient reports occasional rectal itching and pain. He states he has no noticeable sores on his rectal area and no family history of colorectal cancer.
Assessing the Genitalia and Rectum Discussion Case 2: Dysuria
A 55-year-old African-American male reports to your clinic complaining of frequent and painful urination for the past two months. The patient is sexually active and has been in a monogamous relationship for three years. He reports no penile discharge, fever, chills, abdominal pain, or back pain.
His father is deceased and passed away from colon cancer. His father had a history of benign prostatic hypertrophy (BPH). The patient considers himself a healthy male. He works for a large American corporation, has a relatively healthy diet, and exercises 4 to 5 times weekly.
Assessing the Genitalia and Rectum Discussion Case 3: Genitalia
A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient reports no abnormal vaginal discharge.
She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was three years ago, and no dysplasia was found; the exam results were normal. She had one sexually transmitted infection (chlamydia) about two years ago. She completed the treatment for chlamydia as prescribed.
To prepare:
About the case study, you were assigned:
Review this week’s Learning Resources, and consider their insights about the case study.
Consider what history would be necessary to collect from the patient in your assigned case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Week 10 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3
Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five conditions for the patient’s differential diagnosis, and justify why you selected each.
Read a selection of your colleagues’ responses.
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By Day 6
Respond to at least two of your colleagues on two days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
NURS 6512 Week 11 Discussion
Ethical Concerns
As an advanced practice nurse, you will run into situations where a patient’s wishes about their health conflict with evidence, your own experience, or a family’s wishes. This may create an ethical dilemma. What do you do when these situations occur?
In this Discussion, you will explore evidence-based practice guidelines and ethical considerations for specific scenarios.
Scenario 1:
The parents of a 5-year-old boy have accompanied their son to his required physical examination before starting kindergarten. His parents are opposed to him receiving any vaccines.
Scenario 2:
A 49-year-old woman with advanced-stage cancer has been admitted to the emergency room with cardiac arrest. Her husband and one of her children accompanied the ambulance.
Scenario 3:
A 27-year-old man with Crohn’s disease has been admitted to the emergency room with an extreme flare-up of his condition. He explains that he has been unable to afford his medications for the last few months and is concerned about the costs he may incur for treatment.
Scenario 4:
A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and requested that the girls receive a pelvic examination and be given birth control. The girls have consented to the exam but seem unsettled.
Scenario 5:
A 17-year-old boy has come in for a check-up after a head injury during a football game. He has indicated that he would like to be able to play in the next game, which is in 3 days.
Scenario 6:
A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is religious and believes the vaccine would encourage premarital sexual activity.
Scenario 7:
A 57-year-old man diagnosed with motor neuron disease two years ago is experiencing a rapid decline in his condition. He prefers to be admitted to the inpatient unit at a hospice to receive end-of-life care, but his wife wants him to remain home.
To prepare:
Select three scenarios, and reflect on the material presented throughout this course.
What information would need to be obtained about the patient through health assessments and diagnostic tests?
Consider how you would respond as an advanced practice nurse. Review evidence-based practice guidelines and ethical considerations applicable to the scenarios you selected.
By Day 3
Post the explanation of the health assessment information required to diagnose your selected patients (include the scenario numbers). Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. Justify your responses.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who selected different scenarios than you, using one or more of the following approaches:
Suggest additional health assessment information that would be necessary to collect from the patient
Critique your colleague’s response, and explain alternative approaches to the situation.
Validate an idea with your own experience and additional research.
NURS 6512 Week 10 quiz
Question 1 Prostate examination findings of a hard, irregular, painless nodule with obliteration of the median sulcus are signs of:
Question 2 Bimanual examination of the uterus includes:
Question 3 Which of the following is a normal component of vaginal discharge seen on a wet mount?
Question 4 The tail of Spence extends:
Question 5 When should girls be taught to perform breast self-examination?
Question 6 The form of gynecologic cancer that is increased in obese women is:
Question 7 Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You should:
Question 8 A 70-year-old man has a prostate-specific antigen (PSA) value of 6 and a negative digital rectal examination (DRE). These findings indicate:
Question 9 Initial digital approach to the rectal examination should be:
Question 10 The most emergent cause of testicular pain in a young male is:
A history of increases Question 11 The risk of ovarian cancer:
Question 12 A mother brings her 8-year-old daughter to the clinic because the child says urinating after she fell while riding her bicycle hurts. Upon inspection, you find posterior vulvar and gross perineum bruising. These findings are consistent with the following:
Question 13 The mother of a newborn boy tells you that her baby s breasts are swollen and sometimes look like they leak milk. It is most appropriate to tell her the following:
Question 14 Your patient s chief complaint is repeated pencil-like stools. Further examination should include the following:
Question 15 The female patient should ideally be in which position for the pelvic examination?
Question 16 While examining an 18-year-old man, you note that the penis and testicles are more darkly pigmented than the body skin. It would be best if you considered this finding to be:
Question 17 When examining a small child, in which position should he be placed to help push the testicles into the scrotum?
Question 18 A 23-year-old female presents with severe right lower quadrant tenderness. All of the following should be considered in the differential except:
Question 19 What is the initial diagnostic radiology test should be ordered if you suspect a ruptured ovarian cyst?
Question 20 A 17-year-old male was brought into the emergency room with testicular/scrotal pain. The differential diagnosis should include all except:
NURS 6512 Week 11 quiz
Question 1 When interviewing a disabled patient, it is best to speak to:
Question 2 Which of the following is most likely to enhance examiner reliability?
Question 3 Throughout the history and physical examination, the clinician should:
Question 4 At your first meeting with a patient, it is usually best to say:
Question 5 Which of the following is true regarding the relationship between the examiner and the patient?
Question 6 When conducting a geriatric assessment, basic activities of daily living (ADLs) include:
Question 7 Your 15-year-old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. It would be best if you questioned this patient about her:
Question 8 The reliability of health-related findings and observations is the responsibility of the:
Question 9 The cranial nerves are usually assessed while the patient is in which position?
Question 10 The best way to ease the apprehension of a 3-year-old child before a physical examination is to:
Question 11 When you attempt to move a 10-month-old child from his mother s lap to the examination table, he screams. Your best action is to:
Question 12 Palpation of epitrochlear nodes is part of the:
Question 13 Which medical condition would exclude one from sports participation?
Question 14 The greatest risk for potential health problems occurs in which age group?
Question 15 Functional assessment is most important during the examination of a(n):
Question 16 When conveying bad or distasteful news to the patient and family, it is best to:
Question 17 The checkout station for preparticipation physical evaluation (PPE) is critical because, at this point:
Question 18 To promote your examination time with a cooperative child, your approach to the examination should be to:
Question 19 Which data is not part of your general inspection?
Question 20 Part of the orthopedic screening component of the examination includes evaluating the person while:
Assessment is one of the skills that nurses should possess in their practice. Nurses use their assessment knowledge and skills in developing accurate diagnoses and plans of care for their patients. The assessment skills that nurses often use in their practice include history taking and physical examination such as observation, palpation, percussion, and auscultation. Assessment results also guide the evaluation of care given to the patients. Nurses use evaluation information to determine the accuracy of their diagnoses, plans, and interventions used to address the care needs of their patients.
Therefore, this paper is an examination of a case study of client who presented to the clinic with genitourinary problem. The client came with a history of external pumps in her genital area, which are painless and rough. The history obtained from her shows that she had the last pap smear test three years ago, which was normal. The patient does not have any significant medical, family or surgical history. Therefore, the paper examines the subjective and objective data that should be obtained for the patient, diagnostic investigations and differential diagnoses for the client.
Additional Subjective Data
The nurse should focus on obtaining additional subjective data from the patient besides those in the case snapshot. The additional subjective data will guide the development of accurate diagnosis and treatment plan for the client. The nurse should obtain the information about additional symptoms that are associated with the external pumps on her genitalia (Stephen & Skillen, 2020). The nurse should obtain information such as size, shape, any discharge, or changes in the pumps that might have occurred over the past in terms of appearance. The nurse should also obtain additional information about any history of similar pumps in the past.
A history of closely related pumps of the genital area could guide the development of diagnoses such as warts in the patient. There is also the need for the nurse to obtain information related to medication use by the patient. A history of medication uses such as those used in managing the pumps could aid in determining the cause of the problem (Stephen & Skillen, 2020). History on medication use could also guide the determination of whether the pumps are attributable to side effects or adverse reactions to a drug.
Moreover, the nurse should obtain information about the use of any irritants in the past that might have caused the pump. For example, information about the types of soaps that the patient uses should be obtained. The client should also be asked about her sexual preferences. This will provide information about her sexual habits, which might have led to the development of the pumps. The effect of the pumps on the self-perception of the client should also be obtained. The nurse should try to rate the effect of the pumps on her self-image and self-esteem using an appropriate rating scale (Forbes & Watt, 2020). The additional subjective data that may be needed include history of skin problems such as eczema, menstrual history, and occupational history to determine any risk factors in her workplace place.
Additional Objective Data
Additional objective data should also be obtained from the client to increase the accuracy of the diagnosis. The nurse should have performed a rectal examination. The examination could have provided clues such as the presence of hemorrhoids or anal fissures. The nurse should have also provided information about the general appearance of the client. The general appearance could have provided clues on the social, emotional and physical impact of the pumps on the client (Cox, 2019). The nurse should have also performed head to toe examination of the client.
The examination could have included the assessment of the skin to determine the existence of undetected skin lesions. The nurse should have also examined the oral cavity for any lesions, neck for inflamed lymph nodes and neck rigidity. The nurse should have also assessed the chest for any abnormal findings such as appearance, shape, or palpitations on auscultation (Champagne et al., 2017). The above information could have guided the accuracy of the diagnoses made by the nurse.
Whether Subjective and Objective Data Support the Assessment
The assessment is supported by subjective and objective data. Subjective data is the data that the patient provides concerning her experience with the health problem. The information is based on the perceived experiences by the patient and the management of the health problem. Subjective data provides the basis of assessment and physical examinations of the patient. The examples of subjective data that support the assessment include the client’s complaints, history of the complains, history of any vaginal discharge, her Pap smear examinations, and any significant past medical, surgical and family history.
Objective data on the other hand is the data that the nurse obtains using assessment and physical examination techniques. The data is not based on the subjective experiences of the patient with the disease but the physiological changes in the patient due to the disease. Objective data is used to validate the subjective data (Perry et al., 2021). The examples of objective data in the case study include vital signs, auscultation of the heart and lungs and the observation of the genitalia. The diagnostic investigations that were ordered also form part of the objective data that supports the assessment.
Diagnostics
The development of accurate diagnosis of the client’s problem can be achieved by performing a number of diagnostic investigations. One of them is skin scrap. A scrap of the pumps can be obtained for laboratory examination. The other investigation is tzank smear to test for herpes simplex. The client should be tested for syphilis using diagnostics such as Darkfield microscopy or enzyme immunoassay (Perry et al., 2021).
Current Diagnosis
The current diagnosis of chancre is accurate. Patients with chancre present with symptoms similar to those of the client in the case study. For example, the ulcers are asymptomatic and can last for a period of up to six weeks (Cox, 2019).
Differential Diagnoses
One of the differential diagnoses that should be considered for the patient in the case study is contact dermatitis. Contact dermatitis is a skin condition that is characterized by symptoms such as the presence of rashes, which are dry, scaly and cracked. It is however the least likely due to the absence of itchiness and oozing or crusting of the rashes. The second differential diagnosis is syphilis. The client has a history of multiple sexual partners, which predisposes her to syphilis. Patients with syphilis also show skin rashes such as chancre in the early stages of syphilis. The last differential diagnosis is herpes simplex. Patients with herpes simplex may have symptoms such as rashes in the genitals
Conclusion
The diagnosis of chancre in the case study is accurate. Additional subjective and objective data should be obtained to come up with an accurate diagnosis. Differential diagnoses such as syphilis, herpes simplex, and contact dermatitis should however be considered. In addition, further diagnostic investigations should be performed to come up with an accurate diagnosis.
References
Champagne, B. J., Steele, S. R., Hendren, S. K., Bakaki, P. M., Roberts, P. L., Delaney, C. P., … & MacRae, H. M. (2017). The American Society of Colon and Rectal Surgeons assessment tool for performance of laparoscopic colectomy. Diseases of the Colon & Rectum, 60(7), 738-744.
Cox, C.
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